Abstract
Overall, 1 of 5 decedents in the United States is admitted to an intensive care unit (ICU) before death. To describe structures, processes, and variability of end-of-life care delivered in ICUs in the United States. This nationwide cohort study used data on 16 945 adults who were cared for in ICUs that participated in the 68-unit ICU Liberation Collaborative quality improvement project from January 2015 through April 2017. Data were analyzed between August 2018 and June 2019. Published quality measures and end-of-life events, organized by key domains of end-of-life care in the ICU. Of 16 945 eligible patients in the collaborative, 1536 (9.1%) died during their initial ICU stay. Of decedents, 654 (42.6%) were women, 1037 (67.5%) were 60 years or older, and 1088 (70.8%) were identified as white individuals. Wide unit-level variation in end-of-life care delivery was found. For example, the median unit-stratified rate of cardiopulmonary resuscitation avoidance in the last hour of life was 89.5% (interquartile range, 83.3%-96.1%; range, 50.0%-100%). Median rates of patients who were pain free and delirium free in last 24 hours of life were 75.1% (interquartile range, 66.0%-85.7%; range, 0-100%) and 60.0% (interquartile range, 43.7%-85.2%; range, 9.1%-100%), respectively. Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life (odds ratio, 0.70; 95% CI, 0.49-0.99; P = .04), and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death (odds ratio, 1.95; 95% CI, 1.37-2.77; P < .001). Death in a unit with an open visitation policy was associated with higher odds of pain in the last 24 hours of life (odds ratio, 2.21; 95% CI, 1.15-4.27; P = .02). Unsupervised cluster analysis revealed 3 mutually exclusive unit-level patterns of end-of-life care delivery among 63 ICUs with complete data. Cluster 1 units (14 units [22.2%]) had the lowest rate of cardiopulmonary resuscitation avoidance but achieved the highest pain-free rate. Cluster 2 (25 units [39.7%]) had the lowest delirium-free rate but achieved high rates of all other end-of-life events. Cluster 3 (24 units [38.1%]) achieved high rates across all favorable end-of-life events. In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing. To achieve optimal care for patients who die in an ICU, future research should target unit-level variation and disseminate the successes of higher-performing units.
Highlights
20% of people who die in the United States are admitted to an intensive care unit (ICU) at or near the time of death.[1]
Ascertainment of an advance directive was associated with lower odds of cardiopulmonary resuscitation in the last hour of life, and a documented offer or delivery of spiritual support was associated with higher odds of family presence at the time of death
In this study, end-of-life care delivery varied substantially among ICUs in the United States, and the patterns of care observed suggest that units can be characterized as higher and lower performing
Summary
20% of people who die in the United States are admitted to an intensive care unit (ICU) at or near the time of death.[1]. Prior work[18,19,20,21] demonstrated variation among units in the delivery of life-sustaining treatments and cardiopulmonary resuscitation (CPR) at the EOL. Observed unit-level variation in EOL care is not fully explained by differences in patient preferences or characteristics,[18,22] suggesting unit-level characteristics and practice patterns may have an important association with EOL care delivery.[23] Beyond the delivery of CPR and life-sustaining treatments, families of decedents and clinicians in the ICU recognize additional, meaningful events that take place during death and dying in an ICU, such as the presence of family at the bedside and the avoidance of burdensome symptoms near death.[10,11,24,25] Whether these fundamental features of EOL care vary among units within the United States is unknown
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
